95% PASS RATE FOR THE NCS EXAM and 92% PASS RATE FOR THE OCS EXAM › forums › PCS Advantage › L3 level SCI or MM and KAFOs vs AFOs
March 8, 2020 at 7:00 pm #331970
I feel like I keep seeing inconsistencies in prescribing AFOs vs KAFOs for L3 level.
From Campbell for SCI: Children who have at least three-fifths strength in the quadriceps muscles or stronger hip flexors can achieve ambulation with KAFOs.
14. What type of equipment will this adolescent need for functional mobility purposes once he is discharged from the hospital?
a. Manual wheelchair for community distances; RGOs and forearm crutches for community distances
b. Manual wheelchair for community distances; AFOs and cane for household distances
c. Power wheelchair for household distances; unable to ambulate
d. Manual wheelchair for household distances; KAFOs and forearm crutches for ambulation within the household
Patients with SCI at the L3 level require a manual wheelchair for longer community distances and recreation and independently ambulate indoors with AFOs and may need forearm crutches or a cane.
I got this question correct (B) by eliminating D because the would not need manual w/c for household distances. My question is, how do you know they will need AFOs over KAFOs? For this question, are you basing AFOs on 3+/5 strength?
When comparing with myelodysplasia, Campbell states “Children with grade 3 quadriceps strength usually require KAFOs and forearm crutches to ambulate for household and short community distances and a wheelchair for long community distances”
March 8, 2020 at 9:51 pm #332049
I have the same question with #65 — the notes above from Campbell: “Children with grade 3 quadriceps strength usually require KAFOs and forearm crutches to ambulate for household and short community distances and a wheelchair for long community distances”,
65. you determine that the child has strength of at least 3/5 muscle grade in the following muscle groups: hip flexion, hip adduction, knee extension and flexion; and 2/5 muscle grade in the following muscle groups: hip abduction, ankle dorsiflexion, foot inversion, and toe extension.
65. Based on this child’s motor function level, which type of lower extremity orthosis will most likely be prescribed to provide lower extremity support during standing and ambulation tasks?
a. Ankle-foot orthosis (AFO)
b. Knee-ankle-foot orthosis (KAFO)
c. Hip-knee-ankle-foot orthosis (HKAFO)
d. Reciprocating gait orthosis (RGO)
Because the child likely has weak ankle stability and dorsiflexion, AFOs will be preferred to support the distal limb (medial-lateral ankle movement) and facilitate toe clearance (ankle dorsiflexion) during the swing phase of gait. If the child’s knee extensor muscles are weak, a crouched gait posture may be present. An RGO or HKAFO would be most appropriate for a young child with absent knee extension (absent knee and ankle muscle function) and only limited active hip flexion. A KAFO is most appropriate for a young child with weak knee extensor strength but functional hip flexion activity. Because orthoses add weight to the lower limb and influence energy expenditure, careful consideration should be made for the least restrictive device possible.
March 9, 2020 at 10:23 am #332399
Response to: “My question is, how do you know they will need AFOs over KAFOs? For this question, are you basing AFOs on 3+/5 strength?”
Yes, we were basing this on 3+/5 strength, assuming that the adolescent could sustain anti-gravity posture for household distances with the additional support of an assistive device. The key here is household distances vs community distances (where AFOs might not be realistic due to muscle fatigue). Your quote from the Campbell text includes short community distances (in addition to household), which definitely changes the demands of the task. KAFOs are very cumbersome, especially for an adolescent or adult, therefore, the least restrictive orthotic device that supports function would be the best option. Obviously, in a real practice scenario, a PT might start with AFOs and then evaluate function to make sure they are providing sufficient support.
March 9, 2020 at 10:50 am #332400
Response to Question #65: Our reference for this question was the Effgen text (most recent 2nd edition, page 328). A young child (in the case a 4yo) with 3/5 strength in hip flexion/adduction and knee flexion/extension, and 2/5 hip ABD strength should be able to manage standing and ambulation in the classroom and school building with AFOs (may possibly need an assistive device as well). Keep in mind that this question is written in the preschool setting, therefore, the task demands are restricted to that environment.
I agree with the quote from Campbell that a child with 3/5 quadriceps strength sometimes needs KAFOs, especially an older and heavier child. Orthotic prescription in Myelo is not an exact science so these questions are hard to write. In the real world of practice there is a bit more problem-solving to do.
When taking the PCS exam, be sure to also consider the child’s age, task demands, setting, and any other contextual factors related to the question (especially more subtle ones).
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